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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Fa * <br /> Na e: <br /> MX i NA. MA-G'4-ft Y� Page 4-'— of <br /> FIcility dress: City: Inspection Dat <br /> FA#— PR;'i: <br /> I ��/) '� � Program Element: <br /> C <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**.� <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 .Te:Product Type: <br /> Total Capacity: �� ,,� gallons ' <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) .0 Containers (2821) #of Containers: �_ TA#: ! ; o2D0C3(e <br /> 2 Total Capacity: gallons Product Type: <br /> c� c l_ M <br /> (per tank or cumulative for containers by product type) <br /> <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: 66-a Pa 7 <br /> 3 Total Capacity: gallons Product Type: - ref� —�-/��(g yT(' <br /> Install Date: <br /> (per tank or cumulative for containers by product type) Ins <br /> ❑ Tank (2820) lzcontainers (2821) #of Containers: _L TA#: 425j DDr IS <br /> 4 Total Capacity: 46 (� gallons Product Type: I +aaL Vl/�+(e/ rrPfU�P)Q <br /> (per tank or cumulative for containers by product type) � <br /> Install Date: <br /> El Tank (2820) J�Containers (2821) #of Containers: �_ TA#: a�D� <br /> 5 Product Type: L PSP . ��G{l k�'P f'1�ob'dp- <br /> Total Capacity: � gallons �---� <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Total Capacity this Page: 0-7 C) gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: 1Entered Date: <br /> 2-tgL(C) By Initial: '� 3 I I b By Initial: I�] AO <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />